Are responsibility beliefs inflated in non-checking OCD patients?

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Abstract

Cognitive models of obsessive-compulsive disorder [e.g., Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37(Suppl. 1), S29–S52] propose a key role for inflated responsibility for harm. Studies evaluating such beliefs typically use heterogeneous samples including several OCD subtypes. A recent investigation by Foa et al. [Foa, E. B., Sacks, M. B., Tolin, D. F., Prezworski, A., & Amir, N. (2002). Inflated perception of responsibility for harm in OCD patients with and without checking compulsions: a replication and extension. Journal of Anxiety Disorders, 16(4), 443–453] found responsibility to be elevated in OC checkers, but not in non-checking OCD patients, relative to non-anxious controls. In that study, the responsibility measure included checking scenarios, thus leaving the possibility that these findings may have been due to criterion contamination. The present study investigated responsibility beliefs in OC checkers (n = 39) and non-checkers (n = 20), anxious controls (n = 22), and non-clinical controls (n = 69), using measures of responsibility which do not have item overlap with OCD symptoms. Results indicated that both OC groups showed greater responsibility beliefs relative to anxious and non-anxious controls. OC checkers endorsed greater responsibility appraisals than anxious and non-clinical control groups. In contrast, non-checking OCs reported greater responsibility appraisals than non-clinical controls, but did not differ from anxious controls and OC checkers. Results are discussed in the context of the cognitive model of OCD.

Introduction

Cognitive–behavioral approaches to obsessive–compulsive disorder (OCD; Rachman, 1997, Salkovskis, 1985, Salkovskis, 1999) are based on the idea that the appraisal of intrusive thoughts, images, impulses and doubts motivates compulsive behaviors, including washing, checking, and neutralising. The importance of inflated beliefs that one may be responsible for harm to oneself or others lies in two areas: firstly, general beliefs (assumptions) and secondly “on-line” appraisals, which occur as interpretations of the occurrence and/or content of intrusions. The overarching concept of responsibility is specifically defined by Salkovskis, Rachman, Ladoucer, and Freeston (1996) as “the belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes.” Cognitive theories indicate that people suffering from OCD are likely to carry out compulsions if they believe they are responsible for preventing harm in a situation, even if the probability of harm occurring is very small. Moreover, there is evidence that people suffering from OCD believe that not preventing harm is morally equivalent to causing harm (Wroe & Salkovskis, 2000); this means that they are more sensitive to ideas of responsibility for harm arising from omissions.

The results of both descriptive and experimental studies are consistent with the proposed role of responsibility beliefs in OCD. Salkovskis et al. (2000) developed a measure of responsibility appraisals and beliefs and found elevations in harm-related responsibility assumptions and appraisals among OCD patients compared to anxious and non-clinical controls. Lopatka and Rachman (1995) found that experimentally decreasing responsibility in checkers via a contract led to a decline in urge to check. In the Foa, Amir, Bogert, Molnar, and Przeworski (2001) study, OCD patients reported more responsibility, greater urges to rectify, and more distress associated with obsessive and non-obsessive low-risk scenarios compared to anxious and non-clinical controls. Lastly, Shafran (1997) manipulated responsibility through varying the presence/absence of the experimenter during an exposure task. Using a mixed-symptom OC sample, she found that patients in the high responsibility condition reported greater responsibility for threat, greater urge to neutralize, greater perceived probability of threat, and greater distress than those in the low responsibility condition.

Rachman (1993) suggested that responsibility may be inflated in some OCD subtypes, such as checkers, but not in others. Foa, Sacks, Tolin, Prezworski, and Amir (2002) found evidence consistent with this hypothesis: responsibility was found to be elevated in OC checkers, but not in non-checking OCD patients, relative to non-clinical controls. However, in that study Foa et al. (2002) used a measure of responsibility that included several scenarios related to the concerns of checkers (e.g., “You see the knob on a gas oven was left on in a church kitchen”). Their findings may be a product of criterion contamination.

Is responsibility relevant to other OCD subtypes? Clinical reports suggest it is. Some patients with washing or cleaning compulsions express concerns about their responsibility for ensuring that others (e.g., their children) are safe from germs. In addition, patients with obsessions but no overt compulsions often report feeling an exaggerated sense of responsibility for the occurrence of unwanted sexual, blasphemous, or aggressive thoughts; thought action fusion is a specific form of responsibility appraisal (Salkovskis & Forrester, 2002).

The present study sought to assess responsibility beliefs in OC checkers and non-checkers using measures unlikely to be relevant to specific OCD subtypes. OC checkers and non-checkers, anxious controls, and non-clinical controls were studied. We hypothesized that both OCD groups would report greater beliefs and appraisals of responsibility for harm than both control groups.

Section snippets

Participants

Questionnaires were given to individuals meeting DSM-IV criteria for OCD (checking n = 39, and non-checking n = 20), to anxious controls (n = 22), and non-clinical controls (n = 69). All clinical diagnoses were made individually by trained psychologists or psychology doctoral students using the Structured Clinical Interview for DSM-IV. Participants with OCD were classified as checkers or non-checkers based on their primary OC symptom. The OCD patients were recruited from local therapists,

Comparisons on demographic characteristics and clinical symptomatology

One-way ANOVAs and chi-square tests were carried out to compare groups on different demographic characteristics and clinical measures; where main effects were significant, Tukey LSD tests were used. Groups did not differ in age, F(3,146) = .49, P > .6. However, the balance of gender did significantly differ between groups, with anxious controls (2 male, 20 female) and non-clinical controls (28 male, 41 female) having significantly more females than males, χ2 = 9.93, P < .05. All clinical groups scored

Discussion

Consistent with current cognitive–behavioral formulations (e.g., Rachman, 1997, Salkovskis, 1999), our findings indicate that compared to anxious or non-clinical controls, OCD patients are more likely to show elevated levels on measures of responsibility for harm without regard to the presence of checking compulsions as their primary symptom. These findings are different from those obtained by Foa et al. (2002), who found inflated responsibility in OC checkers, but not non-checking OCD patients.

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